Both cadres immediately apply direct pressure to the compound femoral bleed, pack with hemostatic gauze, and apply a mechanical tourniquet 5–7 cm proximal until spurting halts completely. Apply pelvic sheet/binder.

Ceiling (Annexure A, Page 3): BAA cannot insert an IV line and cannot administer IV fluid therapy.

The Problem: External bleed controlled, but patient remains in hypovolemic shock (BP 78/42, HR 138) from occult internal abdominal bleeding. BAA cannot treat central hypovolemia.

🚨 BAA Backup Trigger: Radio dispatch immediately: "Priority 1 trauma with occult internal hemorrhage and shock. BAA crew unable to cannulate. Requesting immediate ILS/ALS intercept on R61 while we transport."

Capabilities (Annexure A, Page 3 & CDST Page 29): *ECA* CAN insert a peripheral IV line (>1 year old), CAN insert an adult IO needle, and CAN initiate conservative crystalloid fluid boluses (100–250 mL IV, titrated to maintain radial pulse or MAP ≥ 65 mmHg).

The Real *ECA* Ceiling (Annexure A, Page 10 & CDST Page 9): *ECA* cannot administer Tranexamic Acid (TXA) (Orange text: ^ANT^/~ECP~ only) and cannot run inotropes/Adrenaline infusions.

🚨 *ECA* Backup Trigger: Pumping liters of crystalloids causes the lethal triad (dilutional coagulopathy, acidosis, hypothermia).

Action: *ECA* establishes IV line, runs conservative 250mL bolus, and calls dispatch for ALS/~ECP~ intercept specifically for IV Tranexamic Acid (TXA) and inotropic support while en route.

Vascular Access: Both cadres initiate peripheral IV access (14G/16G) in limbs/hands for patients >1 year old.

*ECA* Specific Advantage: Holds scope for Adult Intraosseous (IO) insertion if peripheral access fails.

Damage Control Fluid Titration: Administer conservative, warm crystalloid boluses of 100–250 mL IV. Recheck vitals every 10 minutes, titrating strictly to maintain a palpable radial pulse (target SBP ≥ 90 mmHg or MAP ≥ 65 mmHg) to prevent dislodging forming clots ("popping the clot").

The Problem: Despite IV/IO access and conservative fluid challenges, the patient has active internal bleeding and remains in refractory shock (SBP 78/42, HR 138).

The Clinical Ceiling: Neither the *ECA* nor the *AEA* can administer Tranexamic Acid (TXA) or Inotropic / Adrenaline Infusions (both marked as ^ Orange text ^ on Pages 9 & 29: ^ANT^/~ECP~ scope only).

The "Why" for Students: Pumping liters of crystalloids does not carry oxygen and actively washes out clotting factors. The patient needs TXA to halt clot breakdown (hyperfibrinolysis) and inotropic vasopressors to maintain organ perfusion.

🚨🚨🚨The Radio Action: *ECA*/*AEA* initiates rapid transport immediately while radioing for an ALS/~ECP~ intercept rendezvous: "Priority 1 polytrauma with active internal hemorrhage and refractory shock. IV access established, conservative fluids running. Requesting ALS intercept for IV Tranexamic Acid (TXA) and inotropic support en route."

What the ~ECP~ Delivers Upon Intercept:

Antifibrinolytic Therapy: Administers Tranexamic Acid (TXA) 2g IV over 10 minutes (Orange text, Page 29) to stabilize clot structure within the critical 3-hour post-injury window.

Chemical Hemodynamic Support: Prepares push-dose Adrenaline (5–20 mcg boluses) or titrates an Adrenaline IV infusion at 2–10 mcg/min (starting at 5 mL/hr, Page 9) to maintain MAP ≥ 65 mmHg without volume-overloading the bleeding patient.

Point-of-Care Ultrasound: Performs an on-scene eFAST exam (Page 29) to directly visualize free fluid in Morison’s pouch and the pelvis, pre-alerting the receiving regional hospital to activate the surgical trauma team and uncrossmatched blood products prior to ambulance arrival.

Execution (Pages 7 & 10): Manual in-line C-spine stabilization (jaw thrust, no head-tilt), rigid Yankauer suctioning of blood/vomitus, and gentle BVM ventilation at 1 breath every 5 seconds with 15 L/min O2.

Ceiling & Scope Trap: An OPA does not protect the trachea against pulmonary aspiration of blood and stomach acid. If the patient has trismus or intact reflexes, an OPA triggers vomiting. An *ECA* can only place an SGA in cardiac arrest (Annexure A Page 1).

🚨 BLS Backup Trigger: GCS ≤ 8 patient with intact reflexes or trismus who cannot protect their own airway. Action: Maintain basic BVM ventilations, keep airway suctioned, and call dispatch immediately for an ~ECP~ rendezvous to perform Rapid Sequence Intubation (RSI).

Execution (CDST Page 11): Assess for presence of gag reflex:

If gag reflex absent: *ECT*/^ANT^ can insert a Supraglottic Airway (SGA) or perform non-drug assisted endotracheal intubation, confirming with ETCO2.

The Ceiling (Page 11 Fork): If patient has trismus, clenching, or reactive airway reflexes, forcing an airway causes severe laryngospasm, hypoxia, and fatal ICP spikes. RSI is marked as ~ Purple text ~ (~ECP~ ONLY).

🚨 ILS/*ECT* Backup Trigger: Patient needs definitive airway protection but has active muscle tone or trismus. Action: Maintain gentle oxygenation via BVM, position lateral if vomiting, and request ~ECP~ intercept for pharmacological RSI.

Execution (Pages 12–15): Executes full pre-hospital Rapid Sequence Intubation (RSI):

Hemodynamic Pre-Optimization: Administers push-dose Adrenaline (5–20 mcg) to raise MAP ≥ 65 mmHg prior to induction, preventing post-induction cardiac arrest.

Neuroprotection: Administers Fentanyl (3 mcg/kg slow IV, Page 14) to blunt the sympathomimetic reflex spike in intracranial pressure caused by direct laryngoscopy.

Induction & Paralysis: Administers reduced-dose Ketamine (1 mg/kg) or Etomidate (0.2 mg/kg), followed immediately by Rocuronium (1.2 mg/kg IV, Page 13).

Intubation & Verification: Passes cuffed ETT smoothly using a gum elastic bougie; confirms placement immediately with continuous quantitative waveform ETCO2 (35–45 mmHg).

Execution (CDST Page 18): Connect patient to transport mechanical ventilator on lung-protective settings:

Tidal Volume: 6–8 mL/kg Ideal Body Weight (IBW).

Ventilator Rate: 12–15 breaths per minute.

PEEP: 5 cmH2O | Target Saturation: 94–98%.

Target ETCO2: Strictly maintained between 35–45 mmHg (4.6–6.0 kPa).

Post-Intubation Maintenance (Page 16 & 19): In hemodynamically unstable trauma, run continuous Ketamine (0.25–0.5 mg/kg/hr) + Midazolam (0.05 mg/kg/hr) IV infusion.